Basic Information
Provider Information | |||||||||
NPI: | 1861989063 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DARBY | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LYNCH | ||||||||
OtherFirstName: | DONNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 20970 | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820037020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3079964777 | ||||||||
FaxNumber: | 3077738013 | ||||||||
Practice Location | |||||||||
Address1: | 2600 E 18TH ST | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820015511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076337370 | ||||||||
FaxNumber: | 3076337202 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2018 | ||||||||
LastUpdateDate: | 11/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2017040780 | MO | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC.0017245 | CO | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC-2052 | WY | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 490052814 | 05 | MO |   | MEDICAID |